Inspection Reports for
Ashley Rehabilitation and Health Care Center
2600 N 22nd Street, Rogers, AR, 72756
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
60% occupied
Based on a November 2024 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 12, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the use of psychotropic medications, specifically focusing on the prevention of unnecessary use or restraint of residents' ability to function.
Findings
The facility failed to ensure consistent behavior monitoring with antipsychotic medications, failed to prescribe antipsychotic medications for indicated diagnoses, and failed to gradually reduce or eliminate antipsychotic medications for residents with no documented behaviors. These deficiencies affected some residents and were associated with minimal harm or potential for actual harm.
Deficiencies (2)
Failed to ensure consistent behavior monitoring with antipsychotic medications and failed to prescribe antipsychotic medications for an indicated diagnosis for residents #4, #7, and #41.
Failed to gradually reduce or eliminate antipsychotic medications with no documented behaviors for residents #4 and #41.
Report Facts
Number of residents sampled: 5
Number of residents cited: 3
Behavior documentation shifts reviewed: 543
Shifts with no behaviors documented: 524
Shifts with no behaviors documented: 459
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding antipsychotic medication use and behavior monitoring | |
| Administrator | Interviewed regarding appropriateness of antipsychotic medication diagnoses |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 9, 2025
Visit Reason
The inspection was conducted to assess compliance with privacy and confidentiality of residents' protected health information and to evaluate the facility's infection prevention and control program, including hand hygiene practices.
Findings
The facility failed to ensure the privacy and confidentiality of residents' protected health information by leaving computer screens unlocked and visible. Additionally, staff failed to perform proper hand hygiene before and after resident care and medication administration, posing a risk for cross contamination.
Deficiencies (2)
Failed to ensure privacy and confidentiality of residents' protected health information by leaving computer screens unlocked and visible.
Failed to ensure staff performed hand hygiene after care of a resident and before and after medication administration for three residents observed.
Report Facts
Residents affected: 1
Residents affected: 3
Years RN #5 worked at facility: 1
Years RN #5 nursing experience: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #5 | Named in privacy and hand hygiene findings | |
| Director of Nursing | Provided statements regarding privacy and hand hygiene training and expectations | |
| Administrator | Provided statements regarding privacy and hand hygiene expectations and training | |
| Infection Preventionist/Medical Records (IP/MR) | Provided statements regarding hand hygiene practices and training |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 1, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, staffing, nutrition, and staff training at Ashley Rehabilitation and Health Care Center.
Findings
The facility was found deficient in providing scheduled baths/showers to residents due to staffing shortages, insufficient nursing staff to meet resident needs during multiple shifts, failure to serve food items according to the planned menu, and failure to provide required annual in-service training for nurse aides, particularly in dementia care.
Deficiencies (4)
Failed to ensure baths/showers were provided to residents on their scheduled days to promote good personal hygiene and grooming.
Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failed to ensure food items were prepared and served according to planned written menu for 1 of 2 meals observed.
Failed to ensure required annual in-service trainings were performed to ensure staff received the required information/education needed to care for residents.
Report Facts
Shifts reviewed: 7
Scheduled bath/shower days: 3
Brief Interview for Mental Status score: 15
Assessment Reference Date: Sep 7, 2024
In-service training period reviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #29 | Resident | Interviewed regarding missed showers and understaffing |
| Director of Nursing | Director of Nursing | Provided bath/shower documentation and interviewed about staffing and in-service trainings |
| CNA #4 | Certified Nursing Assistant | Interviewed about staffing shortages and inability to complete scheduled showers |
| LPN #8 | Licensed Practical Nurse | Interviewed about nursing staff shortages and workload |
| Administrator | Facility Administrator | Provided grievance logs, staffing schedules, and in-service training records; interviewed about staffing and training issues |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 19
Date: Nov 1, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, medication errors, inadequate staffing, and other regulatory concerns at Ashley Rehabilitation and Health Care Center.
Complaint Details
The complaint investigation was substantiated with findings of emotional abuse by a staff member, failure to investigate abuse allegations timely, medication errors, inadequate staffing, infection control deficiencies, and failure to provide required staff training.
Findings
The facility was found to have multiple deficiencies including failure to prevent resident abuse, inadequate investigation and staff training on abuse, medication errors including unavailable medications, insufficient staffing levels, failure to maintain proper infection control and water management, failure to complete required facility assessments and staff training, and failure to maintain proper food safety and nutrition standards.
Deficiencies (19)
Failed to ensure a resident was free from emotional abuse by a staff member and failed to investigate and train staff timely.
Failed to implement abuse policies and procedures after an allegation, allowing alleged abuser to continue working with residents.
Failed to ensure discharge summaries included complete information such as medication reconciliation and physician signature.
Failed to provide scheduled baths/showers due to understaffing.
Failed to administer CPR as ordered and lacked policy on when to withhold CPR.
Failed to ensure lint traps were free from excessive lint buildup, posing fire hazard.
Failed to provide proper incontinence care in a timely manner.
Failed to assess resident for safety risk before using bed rails and failed to obtain informed consent.
Failed to provide sufficient nursing staff to meet residents' needs for multiple shifts.
Failed to post daily nurse staffing information including facility name, date, census, and hours worked.
Failed to ensure medication was available during administration and failed to prevent medication errors.
Failed to ensure food items were prepared and served according to planned menu and failed to maintain food safety standards.
Failed to establish and implement a governing body policy and failed to involve governing body in facility assessment.
Failed to conduct and document a comprehensive facility-wide assessment including staffing, resources, and policies.
Failed to include all necessary components in arbitration agreements including right to rescind within 30 days.
Failed to provide a neutral and fair arbitration process including selection of neutral arbitrator and convenient venue.
Failed to implement consistent infection surveillance and water management plan to prevent spread of communicable diseases and waterborne pathogens.
Failed to implement an effective antibiotic stewardship program to monitor antibiotic use and adjustments.
Failed to provide required annual in-service trainings including communication, compliance and ethics, and behavioral health.
Report Facts
Medication administration opportunities: 27
Medication errors: 2
Medication error rate: 7.41
Resident census: 60
Staff interviewed for abuse training verification: 14
Staff trained on abuse and neglect: 47
Staff trained on CPR: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named in emotional abuse incident involving Resident #5 |
| Administrator | Involved in abuse investigation and facility management | |
| Director of Nursing | Director of Nursing Services | Involved in abuse investigation, staff training, and interviews |
| LPN #8 | Licensed Practical Nurse | Observed medication administration and medication cart issues |
| RN #9 | Registered Nurse | Observed medication cart and medication availability |
| CNA #7 | Certified Nursing Assistant | Observed providing incontinence care |
| CNA #5 | Certified Nursing Assistant | Involved in shower assistance and abuse incident |
| LPN #7 | Licensed Practical Nurse | Observed medication administration error |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage and labeling regulations in the facility, specifically to ensure drugs and biologicals are properly secured and labeled according to professional standards.
Findings
The facility failed to keep medications secured by leaving them unattended on residents' over-the-bed tables for 4 residents, which posed a potential risk. Observations, interviews, and record reviews confirmed that medications were left unsecured without physician orders for self-medication.
Deficiencies (1)
Medications were left unattended on the over-the-bed tables of Residents #4, #5, #6, and #7 without proper self-medication orders.
Report Facts
Residents affected: 4
Medication counts: 11
Medication counts: 5
Medication counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse #1 (LPN) | Admitted to leaving medications unattended at bedside | |
| Director of Nursing | Provided Medication Administration Guidelines during the survey |
Inspection Report
Routine
Deficiencies: 9
Date: Sep 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, respiratory care, nursing coverage, food safety, infection control, and other aspects of care at Ashley Rehabilitation and Health Care Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter privacy bags, lack of resident access to the State Inspection Book, poor environmental conditions such as urine odor and damaged walls, failure to follow respiratory therapy orders, inadequate RN coverage and absence of a Director of Nursing, improper food handling and storage, failure to follow infection prevention protocols including hand hygiene, and lack of a qualified infection preventionist.
Deficiencies (9)
Failure to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag for Resident #20.
Failure to ensure residents had knowledge of and access to the State Inspection Book.
Failure to provide a homelike environment due to strong urine odor and damaged walls in residents' rooms.
Failure to ensure respiratory orders were followed for 6 residents receiving respiratory therapy.
Failure to provide 8 consecutive hours of RN coverage and failure to designate an RN as Director of Nursing.
Failure to ensure a resident received food prepared according to physician's order for nectar thick liquids without a straw.
Failure to ensure food was covered during transportation, properly stored and dated, and to maintain cleanliness of ice machine filter.
Failure to ensure staff washed hands to prevent cross contamination and infections.
Failure to maintain a qualified infection preventionist with specialized training.
Report Facts
Residents affected: 63
Residents affected: 62
Residents affected: 6
Residents affected: 3
Residents affected: 5
RN hours worked: 4.17
RN hours worked: 6.31
RN hours worked: 1.55
Food trays uncovered: 14
Cake pieces uncovered: 9
Cat food container: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed catheter privacy bag should be in place; confirmed CPAP masks and oxygen tubing storage requirements; confirmed nectar thick liquid diet order |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Confirmed humidifier bottle should be changed every 3 days or once a week; confirmed CPAP mask storage |
| Certified Nurse's Assistant #1 | Certified Nurse's Assistant | Confirmed Resident #50 should have nectar thick fluids without a straw |
| Administrator | Administrator | Confirmed lack of 8 consecutive RN hours and no Director of Nursing; stated efforts to train new Infection Preventionist |
| Dietary Supervisor | Dietary Supervisor | Confirmed cat food stored in kitchen for two years |
| Dietary Manager | Dietary Manager | Confirmed food should be covered and dated; confirmed pineapple cake should have been covered |
| Housekeeper #1 | Housekeeper | Confirmed strong urine odor in Resident #11 room and bathroom |
| Maintenance Supervisor | Maintenance Supervisor | Confirmed wall damage in Resident #48's room and maintenance inspection practices |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed CPAP masks should be stored in a bag when not in use |
| CNA #4 | Certified Nursing Assistant | Admitted failure to wash hands before and after resident care |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Aug 11, 2023
Visit Reason
The inspection was conducted due to a complaint alleging failure to report and investigate suspected abuse, neglect, or misappropriation of resident property involving one sampled resident.
Complaint Details
The complaint involved allegations that a CNA was rough on a resident during showers. The Administrator investigated but did not find evidence of abuse, did not conduct a full investigation including interviews with all staff or residents, and did not document interviews or body audits. Witness statements were incomplete. The Administrator did not report the incident as abuse because the word 'abuse' was never mentioned.
Findings
The facility failed to timely report and thoroughly investigate alleged abuse and neglect involving one resident. The Administrator did not consider the incident reportable as abuse was never explicitly mentioned, did not interview all relevant staff or residents, and lacked documentation of a complete investigation. This failure had the potential to affect all 60 residents in the facility.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to investigate all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property.
Report Facts
Residents affected: 60
Date of survey completed: Aug 11, 2023
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